Consultation Form Please call our office at (888) 489‐3438 or (310) 350-5053 to schedule your consultation. The following form is to be completed at least 24 hours prior to your consultation. If you prefer to print this form and fax it to us, please print this page, or click here to download and print. Health History Questionnaire Personal Information Name Phone Email Address: State: Zip: Occupation: Age: Height: Weight: Blood Type: How long have you been on The Body Ecology Diet?: Describe your current symptoms: What have you already tried that worked well for you? What have you already tried without success? For what reason do you believe it was not successful? What challenges have been getting in the way of accomplishing your recovery and health goals? Family History DiabetesHeart DiseaseAsthmaGallbladder DiseaseKidney DiseaseArthritisStomach DisordersCancer If Cancer, type of Cancer: Other: # of Children: # of Pregnancies: # of Miscarriages: # of Abortions: Complications: MOTHER HISTORY Mother Age: Died from: Grandmother Age: Died from: Grandfather Age: Died from: FATHER HISTORY Father Age: Died from: Grandmother Age: Died from: Grandfather Age: Died from: Habits CoffeeTeaSugarChocolateAlcoholCigarettesDrugsLaxatives Work: hrs/week Sleep: hrs/day Excercise: times/week Please describe what you are currently eating for... Breakfast: Lunch: Dinner: Snacks: What are the three worst foods you eat during the week?: 1. 2. 3. What are the three healthiest foods you eat during the week?: 1. 2. 3. What were your childhood eating habits? (types of foods): List any nutritional supplements you are currently taking, including name brands and amounts: List any prescription medication you are currently taking and dosages: Operations/ Accidents or Injuries (what & when): Health Check List Digestive Tract: NauseaDiarrheaConstipationBloatingBelchinExcess GasHeartburn Ears: Itchy EarsEarachesEar Infectionsear DrainageRinging in EarsHearing Loss Emotions: Mood SwingsAnxietyNervousnessanger/IrritabilityDepression Energy: FatigueApathyLethargyHyperactivityRestlessness Eyes: Watery EyesItchy or Red EyesBlurred VisionTunnel Vission Heart: Irregular heartbeatRapid heartbeatChest pains Joint/Muscle: Joint painArthritisMuscle painVaricose veins Head: HeadachesDizziness Lungs: Chest congestionAsthmaShortness of breath Mind: Poor memoryConfusionLearning Disabilities: StutteringPoor concentration Mouth/Throat: Chronic sore throatSwollen gumsCanker soresSensitive teeth-nerves Nose: Stuffy noseSinus problemsHay feverSneezingExcess Mucus Skin: AcneHives or rashesHair lossExcess sweating Weight: Binge eatingCravingsExcessive weightCompulsive eatingWater retentionUnder-weight Others: Frequent illnessFrequent urinationGenital itchGenital Discharge From the following list, what do you believe might be causing your fatigue? Airborne?Food?Poor Sleep Habits?Thyroid?Stress? Please list your known allergies: Describe your hormone activity (your period as a teen/menopause difficulties): Have you had previous Colon cleansing sessions with a professional colon Hydrotherapist? YesNo If so, when? How many? Are you currently doing colonics or enemas now? YesNo What was your Candida Questionnaire score from The Body Ecology Diet Book? What have some other professionals told you about your health? Metabolic Assessment Form Please list your 5 major health concerns in order of importance: 1. 2. 3. 4. 5. Please choose on a scale of 1 – 4 the appropriate answer to each question below. CATEGORY I – COLON Feeling that bowels do not empty completely:1234 Lower abdominal pain relief by passing stool or gas: 1234 Alternating constipation and diarrhea: 1234 Diarrhea:1234 Constipation: 1234 Hard dry or small stool:1234 Coated tongue of “fuzzy” debris on tongue:1234 Pass large amount of foul smelling gas: 1234 More than 3 bowel movements daily: 1234 Do you use laxatives frequently:1234 CATEGORY II – HYPOCHLORHYDRIA Excessive belching or aching 1‐4 hours after eating: 1234 Gas immediately following a meal: 1234 Offensive breath: 1234 Difficult bowel movements: 1234 Sense of fullness during and after meals: 1234 Difficulty digesting fruits and vegetables; undigested foods found in stools: 1234 CATEGORY III – HYPERACIDITY (ULCER) Stomach pain, burning or aching 1‐4 hours after eating: 1234 Do you frequently use antacids: 1234 Feeling hungry an hour or two after eating: 1234 Heartburn when lying down or bending forward: 1234 Temporary relief from antacids, food, milk, carbonated beverages: 1234 Digestive problems subside with rest and relaxation: 1234 Heartburn due to spicy foods, chocolate, citrus, peppers, alcohol and caffeine: 1234 CATEGORY IV – SMALL INTESTINE (PANCREAS) Roughage and fiber cause constipation: 1234 Indigestion and fullness last 2‐4 hours after eating: 1234 Pain, tenderness, soreness on left side under rib cage bloated: 1234 Excessive passage of gas: 1234 Nausea and /or vomiting: 1234 Stool undigested, foul smelling mucous‐like, greasy or poorly formed: 1234 Frequent urination: 1234 Increased thirst and appetite: 1234 Difficulty losing weight: 1234 CATEGORY V – BILIARY INSUFFICIENCY AND/OR STASIS Greasy or high fat foods cause distress: 1234 Lower bowel gas and or bloating several hours after eating:1234 Bitter metallic taste in mouth, especially in the morning:1234 Unexplained itchy skin: 1234 Yellowish cast to eyes: 1234 Stool color alternates for clay colored to normal brown: 1234 Reddened skin, especially palms: 1234 Dry or flaky skin and/or hair: 1234 History of gallbladder attacks or stones: 1234 Have you had your gallbladder removed? 1234 CATEGORY VI ‐ HYPOGLYCEMIA Crave sweets during the day: 1234 Irritable if meals are missed: 1234 Depend on coffee to keep yourself going or started: 1234 Get lightheaded if meals are missed: 1234 Eating relieves fatigue: 1234 Feel shaky, jittery, tremors: 1234 Agitated, easily upset, nervous: 1234 Poor memory, forgetful: 1234 Blurred vision: 1234 CATEGORY VII – ADRENAL HYPOFUNCTION Cannot stay asleep: 1234 Crave salt: 1234 Slow starter in the morning: 1234 Afternoon fatigue: 1234 Dizziness when standing up quickly: 1234 Afternoon Headaches: 1234 Headaches with exertion or stress: 1234 Weak nails: 1234 CATEGORY VIII – ADRENAL HYPERFUNCTION Cannot fall asleep: 1234 Perspire easily: 1234 Under high amounts of stress: 1234 Weight gain when under stress: 1234 Wake up tired even after 6 or more hours of sleep: 1234 Excessive perspiration or perspiration with little or no activity: 1234 CATEGORY IX ‐ HYPOTHYROID Tired, sluggish: 1234 Feel cold – hands, feet, all over: 1234 Require excessive amounts of sleep to function properly: 1234 Increase in weight gain even with low‐calorie diet:1234 Gain weight easily: 1234 Difficult, infrequent bowel movements: 1234 Depression, lack of motivation: 1234 Morning headaches that wear off as the day progresses: 1234 Outer third of eyebrow thins: 1234 Thinning of hair on scalp, face or genitals or excessive falling hair: 1234 Dryness of skin and/or scalp: 1234 Mental sluggishness: 1234 CATEGORY X – THYROID HYPERFUNCTION Heart palpitations: 1234 Inward trembling: 1234 Increased pulse even at rest: 1234 Nervousness and emotional: 1234 Insomnia: 1234 Night Sweats: 1234 Difficulty gaining weight: 1234 CATEGORY XI – PITUITARY HYPOFUNCTION Diminished sex drive: 1234 Menstrual disorders of lack of menstruation: 1234 Increased ability to eat sugars without symptoms: 1234 CATEGORY XII – PITUITARY HYPERFUNCTION Increased sex drive: 1234 Tolerance to sugars reduced: 1234 “Splitting” type headaches: 1234 CATEGORY XIII (MALES ONLY) ‐ PROSTATE Urination difficulty or dribbling: 1234 Urination frequent: 1234 Pain inside of legs or heels: 1234 Feeling of incomplete bowel evacuation: 1234 Leg nervousness at night: 1234 CATEGORY XIV (MALES ONLY) ‐ ANDROPAUSE Decrease in libido: 1234 Decrease in spontaneous morning erections: 1234 Decrease in fullness of erections: 1234 Difficulty in maintain morning erections: 1234 Spells of mental fatigue: 1234 Inability to concentrate: 1234 Episodes of depression: 1234 Muscle soreness: 1234 Decrease in physical stamina: 1234 Unexplained weight gain: 1234 Increase in fat distribution around chest and hips: 1234 Sweating attacks: 1234 More emotional than in the past: 1234 CATEGORY XV (MENSTRUATION FEMALES ONLY) Are you menopausal? 1234 Alternating menstrual cycle lengths? 1234 Extended menstrual cycle, greater than 32 days? 1234 Shortened menses, less than every 24 days? 1234 Pain and cramping during periods: 1234 Scanty blood flow: 1234 Heavy blood flow: 1234 Breast pain and swelling during menses: 1234 Pelvic pain during menses: 1234 Irritable and depressed during menses: 1234 Acne break outs: 1234 CATEGORY XVI (MENOPAUSAL FEMALES ONLY) How many years have you been menopausal? Do you ever have uterine bleeding since menopause? 1234 Hot Flashes: 1234 Mental Fogginess: 1234 Disinterest in Sex: 1234 Mood Swings:1234 Depression: 1234 Painful intercourse: 1234 Shrinking breast: 1234 Facial hair growth: 1234 Acne: 1234 Increased vaginal, pain, dryness or itching: 1234 Do you smoke? YesNo How many times a week do you eat raw nuts and seeds? How many alcoholic beverages do you consume per week? How many times do you eat out per week? How many times a week do you schedule for workouts? How many caffeinated beverages do you consume per day? How many times a week do you eat fish? Rate your stress levels on a scale of 1‐10 during the average week. 12345678910 MEDICATIONS Check any of the following medications that you are currently taking. AntacidsAntibioticsAntidepressantsAntifungalsAntihistaminesAnti-InflammatoryAnxiety MedicationAsipirin/TylenolDiureticsHigh Blood PressureHigh CholesterolHormones ReplacementsHydrocortisone CreamOral ContraceptivesThyroid Hormones Others
